HomeMy Public PortalAbout5933 1/2 PRIMROSE AVE_Mechanical__ WORKERS'CONIPi{NSATION DECLARATION I CEp 8 B(2-80) A P P I� C AT�O �I FOR PER
R N II � II
I hereby affirm that I irate a' certificate Qf consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-Alba CONDITIONING
a certified copy thereof(Sec.3800. ab,p.)
Policy No .do Company i COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is hereby furnished. ,
e
Certified copy is filed with the county building inspection r BUILDING LI �� �Q�,y� )F A s /?
department. FOR APPLICANT TO FILL IN /� 'rr �1p G
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY A C /y
COMPENSATION INSURANCE I NEAREST �D ! l[NS
(This section need not be completed if the work involved I ABSORPTION UNIT,BTU CROSS ST. ! }>
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. Py.90 SE0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner ,Pr�.r "'Z11151,
so as to become subject to the Workers'Compensation Laws. I BOILER, BTU 0
APPROVALS DATE INSPECTOR'S SIGN RE V
Date Applicant COMPRESSOR,BTU ROUGH �y� d
NOTICE"TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLERVALIDATION
deemed revoked. FURNACE: FAU GRAVITY
_ 4., Vlor
LICENSED CONTRACTORS DECLARATION IFLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED ,UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. 3��d � ,
License Number Lic.Class- 7
� Q
Contractor �' _ Date
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lie.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
ADDRESS
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL.II NO.
7044, Business and Professions Code). CCS
♦ 3 6 9,3 A
I, as owner of the property, am exclusively contracting OWNER � �19 V`7 �NS �
with licensed contractors to construct the project AMAIL DDRESS ! Rp r ) o 0 0 0 0
(Section 7044,Business and Professions Code). ��
�,. /�� � 2 °'° 38.50
CONSTRUCTION LENDING AGENCY CITY L� �'j p' TEL.NO. p` 7 3 a 5 0t).I hereby affirm that there is a construction lending agency o o o
for the performance of the work for which this permit is CONTRACTOR
issued(Sec.3097,Civ.C.). 040 9-82
Lender's Name ADDRESS a
Lender's Address r
CITY
TEL.NO.
l/ b
I certify that I have read this application and state that the 'STATECA
�,� SS
above information is correct.I agree to comply with all County LICENSE NO. L
ordinances and State laws regulating Pleating,Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANUUAGE
County to enter upon the above-mentioned property for
inipcction p rnoses.
Signature of Permittee •Date
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